015601242-12-18-2020-15-AS-AOHN-BWENMC-20201218093454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601242
Report Date: 12/17/2020
Date Signed: 12/18/2020 09:35:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	HEART & SOUL COMMUNITIES		FACILITY NUMBER:	015601242
ADMINISTRATOR:	TILLIS, ERICKA		FACILITY TYPE:	740
ADDRESS:	3770 SUTER STREET		TELEPHONE:	(510) 927-8046
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94619
CAPACITY:	6	CENSUS:	DATE:	12/17/2020
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Licensee Unavailable		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	SENT BY CERTIFIED MAIL ON 12/17/20 DUE TO LICENSEE NOT AVAILABLE An office meeting was attempted to be scheduled on 11/25/20, 11/26/20, 12/08/20, and 12/15/20, but our office did not receive a response. This report was sent by certified mail. On February 8, 2018, the Department concluded a complaint investigation and substantiated an allegation that a resident (R1) sustained multiple pressure injuries due to staff neglect. In addition, an allegation was substantiated that R1 lost a significant amount of weight at the facility due to neglect. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87464(f)(1) – Basic Services for staff neglecting R1 which resulted in R1 sustaining pressure injuries and a 16.7% weight loss over a 5 month period. According to medical records, R1 was hospitalized from December 6, 2016 to December 9, 2016. R1 was admitted to a general acute care hospital for lethargy and not eating or drinking R1’s usual amount. On December 14, 2016, R1 was admitted to the Emergency Room (ER) at a general acute care hospital. The records document a blister that was a Stage 1 pressure injury which was 3 cm in size on R1’s left hip. It did not appear to be infected. The records also document 3 small dermatologic lesions, 1 on left hip, 1 on right hip, and 1 on coccyx. A small laceration was also observed on R1’s buttocks. The hospital prescribed antibiotics for R1. On December 15, 2016, R1 was discharged from the hospital and the discharge instructions indicated facility staff were to monitor the blister and Continued...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEART & SOUL COMMUNITIES	FACILITY NUMBER: 015601242
	VISIT DATE: 12/17/2020

NARRATIVE

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continue wound care for the small laceration on the buttocks. The facility was to follow-up with R1’s primary care physician within 3 to 4 days. There was no documentation in R1’s medical records indicating any home health care or any follow-up appointments.

During Department interview, R1’s public guardian reported conducting a quarterly visit to the facility in April 2017 and observed that R1 had lost a significant amount of weight since R1’s public guardian’s last visit. R1’s public guardian requested for facility staff to take R1 to the doctor to evaluate her weight. Facility staff informed R1’s public guardian that they had difficulty taking R1 to the doctor due to R1’s mobility issues. As a compromise, R1’s public guardian agreed to allow the doctor to make a home visit.

During Department interview, the doctor reported that he made the home visit on May 4, 2017. During the visit the doctor observed that R1 had pressure injuries on R1’s left and right hips. Both wounds had a “really thick sloth” on top of them. The physician applied a dressing on the wounds and told staff that the wounds were beyond their capabilities and advised that R1 be sent to the emergency room.

According to medical records, R1 was admitted to a general acute care hospital emergency room on May 4, 2017 with a Stage 3 pressure injury measuring 5 cm 4 cm on R1’s coccyx, a Stage 3 pressure injury on R1’s left hip measuring 7 cm x 4 cm and a Stage 2 pressure injury on R1’s right hip measuring 8 cm x 5 cm. R1 was also diagnosed with severe sepsis and severe protein malnutrition. According to the Mayo Clinic, “sepsis is a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight an infection. Sepsis occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems.” It was also documented that R1 had a 16.7% weight loss over the last 5 months, which was noted to be “severe per standards.” On May 8, 2017 R1 was discharged from the hospital to a skilled nursing facility.

Continued...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEART & SOUL COMMUNITIES	FACILITY NUMBER: 015601242
	VISIT DATE: 12/17/2020

NARRATIVE

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Based on interviews, record review and observation, the facility staff failed to obtain timely medical attention for R1. The licensee's failure to seek timely care caused the resident to suffer serious bodily injury which required hospitalization and surgery.

At the time of the complaint visit, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, December 17, 2020 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10.000. However, since an immediate civil penalty of $500 was previously issued on February 8, 2018 the amount of the civil penalty issued today will be $9,500.

Appeal Rights, a copy of this report, and LIC 421D provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

LIC809 (FAS) - (06/04)

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